Archived - Audit of the Delivery of Bilingual Services to Visitors by Parks Canada

a) Verify that Parks Canada has an official languages accountability framework.

Parks Canada has a structure for implementing its official languages program. In fact, the National Resourcing Programs Unit is responsible for coordination, monitoring and support to programs related to the Official Languages Act. This unit reports to the Chief Human Resources Officer, who is responsible for implementing the Act. There is also a mechanism for managing complaints regarding official languages. However, many managers we met with said that they do not remember any complaints being filed about their field unit. All the managers who were asked whether they knew who the Official Languages Champion was responded that they did not know that such a person existed. The champion, who is the Vice-President of Heritage Conservation and Commemoration, told us that he plays a leadership role: he is the spokesperson on the Executive Board and must set an example. He also works in cooperation with the Human Resources Directorate and ensures that employees know their language rights.

Parks Canada does not have an accountability framework, a tool required to establish the guiding principles for the effective management of official languages files and to establish and define the roles and responsibilities of the Official Languages Champion, senior executives, managers, team leaders and all employees who are required to communicate with the public. However, according to its draft 2011–2014 official languages action plan, the Agency plans to develop an accountability framework.

Finally, to verify senior management's commitment to official languages, we examined the Parks Canada Agency Corporate Plan 2010–2011 / 2014–2015. Included in the plan is the Parks Canada Charter, which contains the following commitment: "To serve Canadians, working together to achieve excellence guided by values of competence, respect and fairness." It should be noted that neither the Charter nor the plan mentions linguistic duality.

Visitor experience

During the Agency's 2005 reorganization, the External Relations and Visitor Experience Directorate was created to provide national leadership in order to support and achieve the Agency's mandate and in order to guide the work of the following five branches:

• Social Science Branch
• Public Information and Education Branch
• Visitor Experience Branch
• Stakeholder and Partner Relations Branch
• Corporate Communications Branch

Our audit focused on the activities of the Visitor Experience Branch, which is responsible for developing policies, guidelines, frameworks and strategies, and for designing tools and training related to national and local visitor experience objectives. The Visitor Experience Branch also provides national functional leadership to the field units in the areas of planning, interpretive product development, recreational activities, service delivery, promotion, advertising and external communication. It implements national pilot projects and programs, and promotes best practices that help the field units in their operations related to visitor experience. It also manages the day-to-day operations of the Parks Canada campground reservation service as well as the information transaction centre. All of the Visitor Experience Branch's activities are very visible and have a major impact on the general public.

The visitor experience concerns some 21 million Canadians who visit the national parks, national marine conservation areas and national historic sites each year. Parks Canada defines it as the sum total of a visitor's interaction with the protected natural or cultural heritage site that helps him or her create meaning and establish a connection with the place. The visitor experience begins with awareness of the site, followed by planning the visit, travelling to the site, and the welcome and orientation upon arrival. Once on site, the visitor may participate in recreational and interpretive activities and make use of various accommodations, trails, facilities, services and supporting infrastructure, including those pertaining to prevention and enforcement of the Act as it relates to visitor experience. The Agency ensures visitor satisfaction by providing its staff with mandatory Quality Visitor Services training. It monitors the implementation of its quality service standards to ensure consistency and continued service improvement. These activities lead to a sense of personal connection for Canadians. We applaud Parks Canada's commitment in this regard. We do believe, however, that a positive visitor experience must also include the delivery of services of equal quality in English and French, and that the training provided to staff should take this into consideration.

The following diagrams illustrate the Visitor Experience Cycle.

Description – Diagram 1 - The Visitor Experience Cycle and Service

Wishing, planning, travelling, arriving, visiting, departing, remembering

Parkscanada.gc.ca

Bringing you Canada's natural and historic treasures

Description – Diagram 2 - The Visitor Experience Cycle and Service

Our Attributes

• We protect a national network of Canada's treasures
• We present these treasures
• We have knowledgeable and engaging staff
• We provide quality facilities, services and activities
• We inspire people to experience Canada's treasures
• We are a world leader

Our Benefits

• Awe
• Delight
• Discovery
• Appreciation
• Connection

Our Personality

• Welcoming
• Cheerful
• Knowledgeable
• Passionate
• Captivating
• Proactive

Our Essence

• Inspiring discovery

Diagrams provided by Parks Canada

b) Verify that Parks Canada's official languages action plan allows for the effective implementation of Part IV of the Official Languages Act with respect to services provided to visitors at national parks, national marine conservation areas and national historic sites, in person, by telephone, in writing, via electronic systems (including the Internet and social media) and through videos.

Parks Canada has developed a draft 2011–2014 official languages action plan. This plan will be approved by the Management Executive Committee on the recommendation of the Chief Human Resources Officer. The latter is also responsible for coordinating and monitoring the achievement of the plan by the units responsible for its implementation.

The draft action plan aims to achieve compliance with all components of Part IV of the Act. It also refers to language of work (Part V) and equitable participation (Part VI). Our analysis of the plan proved rather negative. The plan's proposed objectives are somewhat vague and lack specific measures to ensure effective and full implementation of Part IV of the Act within the various program areas, such as the national parks, the national marine conservation areas and the national historic sites, which have different realities. The following are excerpts from the plan: "all services are offered in both official languages and are of equal quality," "all oral and written communications are in the official language chosen by the public," and "various approaches have been used with official language minority communities to enable exchanges of information within the Agency."

The plan does not say who is to be responsible for carrying out the activities, nor does it specify timeframes. The responsibility falls to the field units, which is not acceptable. Except for those working in official languages, the employees we met with, including senior executives and managers, were not aware of an official languages action plan. None of the field units in the various regions throughout Canada have an official languages action plan or an operational activity plan based on the national action plan. We believe that plans like these would enable field units across Canada to take their specific situation into account in order to achieve concrete results in terms of bilingual service delivery. We were told that the field unit corporate plans developed over the past two years did not include a review of employees' language requirements, an examination of language profiles for existing bilingual positions or an evaluation of field units' bilingual capacity.

c) Verify that Parks Canada has an official languages policy (or guidelines) that takes into account all of the components relating to services to the public, that is approved by senior management and that is in compliance with the Official Languages Act and the Official Languages (Communications with and Services to the Public) Regulations.

Parks Canada does not have a specific official languages policy; rather, it uses the Treasury Board of Canada Secretariat's Official Languages Policy Framework (2004) and the related Policy on the Use of Official Languages for Communications with and Services to the Public (1999).

These policies are dated and do not accurately reflect the Agency's realities. Many managers and front-line employees we met with said that they were not familiar with the official languages policy, but that the Agency's policies were available on the intranet. The vast majority of staff confused the official languages policy with the Official Languages Act.

In light of the above, and to help Parks Canada remedy this situation, the Commissioner has issued the following recommendation.

d) Verify that Parks Canada is effective in informing all employees assigned to provide services at various sites, either in person or by telephone, about the requirements regarding service delivery in both official languages.

During the audit, the Official Languages Champion sent two e-mails to all personnel: the first was a reminder of Parks Canada's 100th anniversary and the importance of promoting official languages, and the second was about Linguistic Duality Day. Other communications regarding official languages included the following. In 2010, the Chief Human Resources Officer sent one e-mail to mark Linguistic Duality Day and another to present the Translation Bureau's new Language Portal of Canada. In 2008, an e-mail was sent to employees who work in the National Capital Region to inform them about the Rendez-vous de la Francophonie. The Official Languages Specialist at the Western and Northern Service Centre sends information to a specific network of employees who are interested in official languages. For example, an e-mail was sent to remind staff about their obligation to make the active offer of bilingual services (Hello! Bonjour!) during the Vancouver 2010 Winter Olympic and Paralympic Games. Other e-mails included an attachment that contained the Office of the Commissioner of Official Languages' e-newsletter, Beyond Words. Most people we met with said that they had not received information about official languages or about Parks Canada's requirements, except during training on the active offer of bilingual services. We also noted that official languages were not included among the topics presented during the orientation session for new employees held in June 2011.

It is important to mention that many front-line employees do not have access to computers or the intranet, nor do they have a work e-mail address. Because of this, a note appears at the bottom of the e-mails to remind managers that they need to make sure that all employees receive the information, including attachments, either by posting it, by distributing it or by any other appropriate means. Our interviews revealed that, despite the note at the bottom of the e-mails, employees do not always receive information sent by e-mail.

Our audit showed that employees are not always effectively informed of official languages issues and related activities. We also noted that the National Office unit responsible for coordinating and monitoring the official languages program is not very visible, nor is it well known to the field units. Given this situation, we encourage the Agency to publicize the unit's roles and responsibilities as well as its requirements related to all aspects of equal quality service delivery in English and French, whether it be through information bulletins, through a formal network of official languages coordinators representing field units across Canada, within the framework of its training modules, or by any other appropriate means.

e) Verify that the training modules for Parks Canada employees include the Agency's obligations and employees' responsibilities pertaining to official languages.

As mentioned at the beginning of this report, Parks Canada is targeting its strategies and activities more towards the visitor experience. This initiative includes training in the active offer of bilingual services, which is provided to all front-line employees and all staff, including managers, who are required to interact with visitors. This mandatory training is given each year at the start of the summer season to ensure that all relevant personnel understand the active offer, one of the components of Part IV of the Act. A kit including a standard presentation was developed for the trainers. Employees told us that they had not received any other official languages training.

In terms of second-language training, our interviews revealed that it is offered mainly to senior executives and managers. Other employees are encouraged to take courses outside of work hours and during the winter, when tourist sites are closed. Employees can also use their learning plan to indicate their interest in taking second-language training. The Official Languages Training Guide is available on the intranet to provide employees with information on second-language learning.

"We need to look at a strategy to encourage opportunities for language development such as exchanges, learning opportunities to improve second language competency. That does not exist." – Manager

"I took French training on my own." – Lock operator

It is our opinion that Parks Canada could use the training sessions given at the start of the summer season to educate its staff about all of the components of Part IV of the Act, especially the bilingual service delivery that must follow the active offer. We also believe that the Agency should determine methods to provide its entire staff with language and retention training.

f) Verify that Parks Canada takes official languages into account in the performance evaluations of senior executives, managers and employees with service delivery responsibilities.

The performance evaluations of senior executives and managers who have bilingual service delivery responsibilities, including employees who negotiate service agreements with third parties, do not contain objectives related to official languages. Moreover, the performance of employees who are required to communicate with visitors in English and French is not evaluated in terms of services provided in both official languages, except in the cases of Visitor Services attendants in the Banff field unit and staff who perform duties specifically related to the official languages program. The criterion included in the Banff evaluation report focuses solely on the active offer of bilingual services as a performance factor in the employee's ability to communicate. Senior executives and managers told us that performance objectives were included in their performance agreements only if problematic situations occurred in their field units. It is our opinion that Parks Canada should encourage a proactive approach rather than reacting to problems.

g) Verify that partnership agreements with various governments and contracts negotiated with third parties take Parks Canada's language obligations into account.

We sought to determine whether the service agreements with third parties (i.e., businesses that act on behalf of Parks Canada) contained a clause describing the Agency's official languages obligations. We obtained copies of the contracts of associations acting as partners or stakeholders that manage the shops located in the welcome centres (selling books and souvenirs), concession holders who manage the snack bars, and camp grounds and security companies (commissionaires).

We learned that some national historic sites are managed by different organizations that work together with Parks Canada. This is the case for the Gulf of Georgia Cannery National Historic Site. We examined the service agreement between Parks Canada and the company that manages the site. The agreement, which was in effect from April 1, 2007, to March 31, 2010, and extended until 2011, clearly stipulates the company's obligation to provide services in both official languages in person, by telephone and in writing. The following is an excerpt:

The agreement also states that Parks Canada will provide translation help to the company. Parks Canada's requirements regarding the delivery of services of equal quality in English and French are clear and specific in this agreement, and we are satisfied.

We cannot say the same for the other partnership agreements we examined, however. We noticed that the language clauses are not the same in all contracts. More specifically, the agreements with cooperating associations state that the associations must "make every effort to provide services in both official languages." Parks Canada needs to insist that the partners with whom it has agreements do more than "make every effort" to provide services: they should provide services in English and French at all times to meet the Agency's obligations under Part IV of the Act. We believe it is important to remind all partners that they are required to provide services of equal quality in English and French throughout Canada. The Agency should identify corrective measures to implement in the event of non-compliance. In a national park, we observed that a partner company supplied Parks Canada with only one bilingual officer out of six even though the Call-up Against a Standing Offer for Commissionaires specified the need to recruit bilingual security officers. We also noted, in another service request, that Parks Canada had not specified its official languages obligations, nor had it included an official languages clause; however, the Agency had budgeted funds for a bilingualism bonus. The Agency needs to regularly verify whether third parties are providing services in both official languages to ensure that its obligations under section 25 of the Act are being met. This subject is also discussed later in this report under Objective 4 on monitoring mechanisms.

"There are problems in the shops and restaurants because the employees are unilingual." [translation] – Interpreter

a) Verify that Parks Canada actively offers and provides services in both official languages at national parks, national marine conservation areas and national historic sites. Verify that the services provided in person, by telephone, in writing, via electronic systems (including the Internet and social media) and through videos are of equal quality in English and French.

First, we should mention that Parks Canada has been the subject of a number of complaints regarding a lack of French outside Quebec. In the past three years (2007–2008 to 2010–2011), the Office of the Commissioner of Official Languages has received 32 complaints, primarily regarding a failure to provide the active offer and bilingual service. Most of the complaints involved national parks. To address the problems related to the active offer of bilingual services, Parks Canada created the Hello! Bonjour! tool kit, which includes a video and various tools for employees. We congratulate the Agency on its efforts—the video has served as a model for other institutions in similar situations.

When Parks Canada was evaluated for the Office of the Commissioner of Official Languages' 2008–2009 report cards, it received a C (Fair) rating. The active offer in person was made in only 39% of cases. Visual active offer was made in 92.9% of cases and in-person services were provided in the language of the client's choice in 88.9% of cases. For services provided by telephone, active offer was made in 81.8% of cases, and service was provided in the minority language in 80.3% of cases.

"Sometimes the visitor will tell us if they are not happy, such as wanting a Francophone guide." – Interpreter

b) Verify that the bilingual skills of employees at all Parks Canada sites are sufficient to ensure the provision of services of equal quality in English and French.

Our audit found that Parks Canada is finding it difficult to hire personnel, even unilingual personnel, because of the remoteness of its sites and the lack of job security. As mentioned above, many positions are seasonal and often go to students recruited through the Federal Student Work Experience Program. During our interviews, managers stated that this method of recruiting has two drawbacks: first, students do not provide an accurate language profile and, second, they are not always willing to work in remote areas. This program recruits high school, college, technical and university students and electronically matches them with available jobs using skill codes provided by Parks Canada and information from the students' resumés. Students' language skills are also a problem, because their second-language skills are not evaluated. To remedy this situation, we encourage the Human Resources Branch to carefully review this practice in order to help managers. We also encourage managers to consult with human resources advisors, who may be able to suggest other recruitment methods.

During our audit, we sought to determine the bilingual skills of the employees in various field units. To do this, we reviewed the language requirements of positions and the language profiles of employees who are required to communicate with the public in both official languages. We also examined the organizational charts of the field units we visited as well as the generic work descriptions of managers (Visitor Experience), team leaders (of interpreters and attendants), interpreters, Visitor Services attendants, lock operators, and enforcement officers.

Our analysis revealed anomalies in the language requirements and profiles for positions. Although generic work descriptions exist for each group of employees we examined, the language requirements vary for identical positions within a single team or field unit. For example, the language profile of an interpreter position sometimes requires Level B and sometimes Level C. Some interpreter positions require second-language skills only for oral interaction, while others require all three skills: reading comprehension, written expression and oral interaction. Our analysis showed similar results for interpreter coordinators, team leaders and Visitor Services attendants. This system leads to confusion and complicates the management of the language skills required for the Agency's positions. It is important to remember that language requirements are established based on the complexity of subjects handled by the incumbents. In our opinion, the positions of interpreter coordinator, interpreter and team leader should require Level C because the incumbents need to be able to provide explanations that may lead to discussions and exchanges of complicated ideas. Many of the interpreters we met with told us that they had to write and translate their own interpretive programs. As for the other positions, the institution needs to define language profiles after conducting an objective analysis of the incumbents' duties and responsibilities. A good number of managers and team leaders we spoke with were somewhat familiar with the language profiles of different positions and the methods used to determine the language skills required. All of the above-mentioned issues are something to be concerned about, and the Agency needs to take a closer look at the situation.

"We try to change the linguistic profile of the positions as people leave or take retirement." – Senior Executive

In our opinion, Parks Canada needs to use its human resources management system and consult with its field unit managers to carefully evaluate its bilingual capacity so that it can accurately identify any shortcomings and take necessary action. This evaluation will help it standardize the language requirements for similar positions in all field units in order to provide services of consistent quality in English and French. Parks Canada also needs to improve its official languages governance in order to establish the language profiles of bilingual positions and determine the bilingual skills required for front-line services.

In our interviews, we discovered that there are unilingual employees in bilingual positions, which is not acceptable. The institution needs to examine these positions and determine which employees do not meet the language requirements of their positions. Since, at Parks Canada, the managers determine the language profiles and requirements for positions and have the necessary staffing authority, we encourage the institution to implement a mechanism for consulting managers, along with mandatory training, so that language requirements and profiles are appropriate and consistent throughout the organization and reflect the realities and duties of the positions. This needs to be done in the near future, and the necessary measures need to be taken quickly.

"The language requirement of my position is BBC, and my profile is BBB. I was grandfathered in." [translation] – Interpreter

"My job is bilingual imperative at level BBB. I have BBA." – Team leader

Our review of the work descriptions found that the managers' work description includes the requirement to "create and maintain networks with partners and interested parties." We believe that this statement also applies to official language minority community organizations. The work descriptions of the other positions also include a statement indicating that the incumbents must communicate with visitors or interested parties to provide interpretive programs and activities, to respond to requests for information and to provide information in person, by telephone and electronically on activities, services, facilities regulations and various notices. Parks Canada must therefore establish consistent language profiles for all the positions listed above and consider the fact that the language profiles of some of these positions need to be raised.

Our audit included a review of the number of bilingual employees who are required to communicate with visitors. We found there to be a significant lack of bilingual employees in certain groups and a lower percentage of them in field units located in Western and Northern Canada. The Quebec field unit had a low percentage of bilingual Visitor Services attendants, while Newfoundland and Labrador had a low number of bilingual interpreters and Visitor Services attendants. Please note that this data is approximate.

We examined the bilingual skills of the enforcement officers separately because they fall under headquarters' responsibility. Our analysis of the organizational charts for this employee group revealed that a very low percentage of enforcement officers are bilingual. The language profile of enforcement officers with supervisory responsibilities requires only a Level B for oral interaction skills, whereas the language requirement for enforcement officers is BBB.

"Law enforcement staff at this unit is not bilingual." – Senior executive

The above information shows that the bilingual capacity and language profiles established for certain groups of employees at many sites are not sufficient to provide service of equal quality in English and French. This can have a negative impact on work organization and the planning for the provision of bilingual services. The following statements support the results of our analysis.

"The bilingual capacity is not sufficient; we can move staff from the visitor centre, but it's difficult." – Team leader

"There are gaps; there are not always bilingual employees available to cover leaves." [translation] – Manager

"I work five days a week. When I am off, I am not replaced by a bilingual attendant." – Visitor Services attendant

"Bilingual capacity-analysis is not done in a structured manner, although we identify the gaps." – Manager

"It can happen that a unilingual leader is alone on site." – Manager

a) Verify that Parks Canada has initiated an internal reflection process in order to consider the impact of the DesRochers decision on its programs and on how it plans for the provision of bilingual services, and identify how it consults with representatives of official language minority communities in all provinces to determine their service needs and how these communities are informed of the Agency's decisions.

We sought to learn how official language minority communities were consulted—and who conducted the consultations—when developing the Agency's programs and activities. Our interviews revealed that two people in the National Resourcing Programs Unit are responsible for liaising with Canadian Heritage and report, on behalf of the Agency, on the implementation of Part VII of the Act. Field units are responsible for implementing local positive measures to ensure the vitality of official language minority communities across the country and to promote linguistic duality.

In our interviews with representatives of official language minority communities in several provinces, we learned that Parks Canada had not consulted them to determine their needs regarding Parks Canada activities and programs and the planning for the provision of bilingual services. We were not able to obtain the terms of reference, agenda, minutes or any other official document that contained specific information about these meetings. We learned that, although the field units' external relations managers would communicate with members of these communities working in such sectors as education, these discussions were not held with the specific objectives of a formal consultation. For example, we learned that the Jasper field unit shares its premises with the Association canadienne-française de l'Alberta so that the Association's members can offer French classes to the community, which are then also available to Parks Canada employees. In our interviews, we also learned that some of the Agency's employees occasionally attended events organized by official language minority community associations, or events or meetings in which interested parties were invited to participate, including Parks Canada public consultations. The objective of these meetings, however, was not to consult representatives of official language minority communities and discuss their specific needs in terms of Parks Canada programs and activities. The representatives we interviewed said that discussions with field units tended to be between people who know each other. These practices are not synonymous with formal consultation.

The Agency told us that it holds public consultations every five years when developing its management plans. These consultations, which involve community partners, do not seek specifically to learn the particular needs of official language minority communities. It is our opinion that the Agency could benefit from formal consultations with these communities and could include them in its management plans. However, consultations with official language minority communities need to be more frequent than the public consultations, which are held every five years. They should be held as soon as Parks Canada initiates its programs and services review.

In our opinion, Parks Canada needs to establish a dialogue with official language minority communities and majority organizations across Canada (such as Canadian Parents for French), which could help them in their efforts to recruit permanent staff, seasonal workers and students from these communities.

"We do not promote our positions well because we do not have contact with official language minority communities." [translation] – Manager

During our audit, we sought to determine how Parks Canada is taking the DesRochers ruling into account when developing and implementing its programs. The information we obtained showed that the work had yet to be completed, because Parks Canada had not begun its review of existing and upcoming programs and services since formal consultations had not taken place and the needs of the pertinent official language minority communities were not known. However, the Agency has told us that it has included this provision in the draft version of its official languages plan, it has consulted its legal services branch to better understand the impact of the ruling on its activities, and it has examined the analytical grid provided by the Treasury Board of Canada Secretariat's Office of the Chief Human Resources Officer.

a) Verify that Parks Canada has effective monitoring mechanisms (including internal auditing) to ensure that all of its services are of equal quality in both official languages.

Parks Canada conducts surveys every five years in all its national parks, national marine conservation areas and national historic sites in order to evaluate its service delivery. The results are taken into account in activity planning and management. The survey questionnaire is in English and French and includes a specific question on whether visitors were served in the official language of their choice. To analyze bilingual service delivery, we looked at the results of three surveys on the Visitor Information Program: one conducted in 2006 at Fundy National Park, a second in 2007 at St. Lawrence Islands National Park, and a third in 2010 at Banff National Park. The results for Fundy and Banff were "very satisfactory," with service received in the minority language in 89% and 82% of cases, respectively. The results were much less satisfactory for St. Lawrence Islands, which scored only 59%. For this survey, 7% of respondents indicated that they were "not at all satisfied" with the service provided in the minority official language.

In our on-site visits, we examined the cards various field units use to measure client satisfaction. The formats varied from site to site. Some cards, which said "Your comments are useful in our efforts to improve the quality of your visit," had a blank space for visitors to write their comments. Others asked specific questions and had a space for comments. None of the cards had questions about the availability or the quality of services offered in the official language of the visitor's choice. We encourage Parks Canada to develop uniform tools to measure visitor satisfaction regarding official languages and to include a question about services provided in English and French.

"I don't know of any control mechanisms." – Manager

Some managers told us that they thought they had had visits from Parks Canada mystery shoppers; however, they had not received any results regarding these supposed visits.

Apart from the foregoing, Parks Canada does not have official monitoring mechanisms to evaluate the results of its activities and programs in terms of Part IV of the Official Languages Act. Our audit also found that the Agency had not established procedures to monitor and evaluate the performance of third parties with whom it has agreements that include language clauses.

Official languages have not been audited internally since the creation of the directorate responsible for them. However, it is encouraging that the Agency plans to conduct an audit in 2014–2015 of its responsibilities under the Act with respect to identifying, maintaining and staffing bilingual positions, and creating a work environment conducive to the use of both official languages. Our audit is therefore quite timely, as shortcomings have been identified regarding the staffing of bilingual positions, in terms of language requirements, language profiles of bilingual positions and the number of bilingual incumbents required. Parks Canada also needs to examine how it plans for the provision of bilingual services, which affects the quality of services provided in English and French. We encourage the internal audit branch to closely monitor Parks Canada's progress after implementing the Commissioner's recommendations in this report.

b) Verify that the results of the monitoring are used in service quality management in order to ensure continued improvement and tangible results.

In terms of monitoring and quality management results, Parks Canada still has work to do, because it has yet to establish formal monitoring mechanisms for all components of Part IV of the Act in order to achieve continued improvement and tangible results.